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and individually recruited to complete the pre-/post-

assessments.

Program Design

START combined instruction in Photovoice methods with

educational sessions addressing asthma self-management.

Program goals were two-fold: (1) enable participants to

identify and address multi-level factors affecting asthma

self-management, and (2) improve community asthma

awareness through the production, dissemination and

evaluation of two student-directed PSAs.

Phase I (Photovoice)

Two initial sessions were designed to introduce student

participants to program goals and fundamentals of ethno-

graphic research. In subsequent sessions, student partici-

pants were given basic training from a photographyinstructor as well as daily photography and journaling

assignments. Over the remaining weeks, student partici-

pants framed their day-to-day lives through journal entries

and photographs in order to identify and discuss answers to

the following research questions: (1) What is your com-

munity? (2) What things in your community affect your

health? (3) What things in your community hurt or help

your asthma? (4) What are the most significant barriers to

your asthma management? (5) How can you improve or

control your asthma? Additionally, five of the twenty ses-

sions included asthma education components led by pedi-

atricians and medical students. For further detail onprogram development and design, see Gupta et al. [33].

Phase II (Public Service Announcements)

In the second phase of the program, photography and

videography experts worked with student participants to

incorporate student photographs and storyboard concepts

into two PSAs via a 4-week iterative, student-directed

process This process began with students brainstorming

potential narrative structures for each video, filling in blank

boxes, which constituted a timeline for each PSA, with

their pictures and commentary. Each week the videogra-

pher would synthesize students footage and storyboard

suggestions into a pair of draft PSAs and bring them back

to the students in the following week for refinement until

students were satisfied. Each final PSA, described below

and available at http://youtu.be/bEp2fakobtM and http://

youtu.be/yyCQRUG2Zfk, focused on a single question

What is asthma? and What can my community do to help

kids with asthma? Students showcased the PSAs to peers

and community members at a school-wide premiere.

Public Service Announcements

PSA 1, What is Asthma? (1:07 min)

The PSA starts with the question Did you know? fol-

lowed by three asthma statistics, a definition of asthma,

three consequences of asthma, and an example of how to

control asthma. Cartoon animations and student faces fillthe screen, accompanied by student commentary. The PSA

ends with students emphasizing their ability to do any-

thing anyone else can if I take care of my asthma and

provides a resource for viewers desiring more information.

PSA 2, What can my Community do to Help Kids

with Asthma? (1:28 min)

The PSA depicts a female, African-American high school

student in black and white standing in front of a collection

of photographs with slow music playing. One-by-one she

drops photographs depicting six community asthma trig-gers onto a table. The music becomes upbeat, the images

turn to color, and the student now drops photos that depict

four community asthma aids. The PSA ends encouraging

viewers to become active in reducing community asthma

triggers and again provides a resource for viewers desiring

more information.

Outcome Measures

Phase I (Photovoice)

Phase I outcomes are reported in Gupta et al. [33].

Phase II (Public Service Announcements)

Pre-PSA, immediate post-PSA, and 4-month post-PSA

follow-up assessments were conducted to evaluate changes

in community members asthma knowledge immediately

before and after as well as 14 months after viewing the

PSAs. Assessments evaluated participant knowledge of the

definition of asthma, statistics presented in the PSAs, and

asthma-related morbidity, as well as community aids and

triggers. Demographic characteristics and data on prior

experiences with asthma were also collected. In addition,

self-reported changes in awareness and behavior were

documented during the 14 month follow-up telephone

survey.

Statistical Analysis

Relative frequencies of correct responses for the pre-PSA,

immediate post-PSA, and 4-month post-PSA follow-up

assessments were calculated. T-tests were performed to

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Eighty-six percent (n = 31) of participants felt they knew

more about asthma at follow-up, with participants citing

community asthma aids (22.5 %) and the prevalence of

asthma (19.4 %) as the most important facts imparted by

the PSAs.

Seventy-five percent (n = 27) of follow-up telephone

call respondents reported that the PSAs improved their

awareness of community triggers and aids, with smoking

being most commonly identified (51.9 %). Thirty-nine per-

cent (n=14) of these respondents reported behavior

changes in response to the PSAs, most often in the form of

smoking less (35.7 %). Other reported behavior modifica-

tions included using public transportation andmaking efforts

to improve air quality by planting trees/or other plants.

Discussion

Student-directed PSAs, developed as part of the START

intervention, were found to significantly increase asthma

Table 2 Knowledge scores pre-/post-viewing PSAs

Item Correct response (%)

All participants(n =228)

Had asthma and/or household member with asthma(n =89)

Pre Post Gain Pre Post Gain

Asthma definition

Lungs* 31.1 75.0 ?43.9 47.2 98.9 ?51.7

Inflammation* 7.0 52.2 ?45.2 9.0 62.9 ?53.9

Asthma statistics

Prevalence of asthma among children in Chicago* 7.0 66.7 ?59.6 10.1 84.3 ?74.2

Prevalence of asthma among children in the neighborhood* 11.8 63.6 ?51.8 12.4 80.9 ?68.5

Economic cost of asthma per year in the US* 3.5 55.3 ?51.8 4.5 69.7 ?65.2

Asthma morbidity

Miss school* 1.3 19.3 ?18.0 0.0 25.8 ?25.8

Hospitalization* 5.7 13.2 ?7.5 10.1 15.7 ?5.6

Stigmatization* 0.9 3.9 ?3.1 2.2 6.7 ?4.5

Decreased participation in sports 17.5 5.7 -11.8 21.3 9.0 -12.4

Death 37.7 18.0 -19.7 59.6 27.0 -32.6Asthma attack 60.1 39.5 -47.0 82.0 42.7 -39.3

Community triggers

Alcohol/drugs* 6.6 51.3 ?44.7 10.1 69.7 ?59.6

Tobacco smoke* 56.1 75.9 ?19.7 79.8 102.2 ?22.5

Stress* 5.3 13.6 ?8.3 6.7 21.3 ?14.6

Air pollution* 53.9 61.8 ?7.9 71.9 82.0 ?10.1

Violence* 4.4 9.2 ?4.8 6.7 15.7 ?9.0

Stigmatization* 2.6 3.5 ?0.9 3.4 3.4 0.0

Strenuous exercise 8.8 3.5 -5.3 11.2 5.6 -5.6

Strong odors 10.1 2.2 -7.9 18.0 5.6 -12.4

Weather 11.8 1.8 -10.1 24.7 4.5 -20.2

Allergens 19.7 3.9 -15.8 30.3 7.9 -22.5

Dirty environment 28.1 10.1 -18.0 40.4 12.4 -28.1

Community aids

Stress-free environment* 0.9 25.4 ?24.6 0.0 32.6 ?32.6

Access to healthcare* 24.1 38.2 ?14.0 39.3 50.6 ?11.2

Supportive community* 5.3 7.0 ?1.8 5.6 12.4 ?6.7

Clean air* 16.2 14.5 -1.8 19.1 13.5 -5.6

Asthma education/awareness* 14.0 9.6 -4.4 21.3 12.4 -9.0

Healthy lifestyle* 15.8 4.8 -11.0 25.8 4.5 -21.3

* Factors addressed in the PSAs

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knowledge among community members, irrespective of age,

gender, or race. Increased knowledge persisted at 14 months

post-PSA follow-up. Of the thirty-six participants who

were successfully contacted for the follow-up survey, nearly

40 % reported meaningful behavior-change in response to the

PSAs.

Many asthma interventions have embraced the socio-

ecological model and thus incorporate home, school, andcommunity-based components to address the multi-factorial

nature of asthma self-management [18,34]. However, the

majority of school-based asthma interventions have targeted

pre-adolescent youth, often with mixed results [35]. Among

the few school-based interventions designed specifically for

adolescents, the Classical Health Promotion model pre-

vails, in which a prescribed, knowledge-based curriculum is

presented in a didactic manner by experts [36].

Though our intervention incorporated such didactic

sessions, most learning was imparted through student-led

and hands-on investigation into factors affecting asthma in

the context of each students unique environment. Webelieve that this more collaborative, community-based

approach may have helped to bridge the gap between each

individual student and his or her community [37], making

each PSA all the more personally relevant. A similar

approach was used by Shah et als Adolescent Asthma

Action(Triple A) program [38]. Much like our intervention,

Shah et al. found the program to be well-received and

effective at increasing asthma knowledge; Shah also

observed improvements in asthma-related quality of life

among participants. Future work will be needed to link the

effect of a Photovoice intervention like ours to specific

clinical outcomes.While most Photovoice interventions seek to create

community-level change, few efforts have been made to

evaluate the impact of such projects within the community

[39]. In the grand majority of Photovoice projects with an

advocacy component, public photo exhibitions are utilized

to present participants photos to community stakeholders

[39]. To our knowledge, START is the first program to uti-

lize Photovoice techniques as an instrument to create PSAs

for the purpose of community health promotion. Public

service announcements have long been used as a social

marketing tool in public health [40], and may be particularly

effective in communities with low literacy and limited

educational opportunities, such as is often the case in low-

income urban environments. Additionally a substantial

CBPR literature supports the idea that PSAs generated from

within the community may be more effective at reaching

community members both by nature of relevant content and

acceptable format to the intended audience [41].

It is important to note that the PSAs were effective at

improving knowledge among community members of all

age groups, not just the students peers. In fact, knowledge

scores increased most among older participants (ages

2145 years). Such findings hold promise for the role of

future school-based interventions in the promotion of

healthy behaviors at the individual and community level.

Taking Photovoice methods one step further, a recent

project conducted by Catalani et al. [42] incorporated

participatory videography, which is suggested to be an

effective way to mobilize community in the production anddissemination of findings [43]. Given the dynamic nature

of video and the creative flexibility it affords, as well as

rapidly decreasing costs, we recommend that future inter-

ventions incorporate participatory videography into the

START curriculum. This approach will likely expand the

students purview while allowing for more robust integra-

tion of their footage directly into the PSAs, further

empowering participants. Moreover, the increasing ubiq-

uity of video-editing software provides students, with little

prior experience, an opportunity to create their own

PSAs with relatively little expert supervision. Finally, the

growing popularity of video sharing sites likeyoutube.com,which provides automatic captioning and translation of

videos into dozens of languages, provides a means to

disseminate video content to an ever-growing online

audience.

This study has a number of limitations. The PSAs

focused predominately on negative environmental factors

that contribute to asthma exacerbations and were reflective

of the personally relevant factors affecting asthma identi-

fied by students in this feasibility pilot study. Additionally,

since few adults identified their highest level of education

completed, we are not able to draw evidence-based con-

clusions about the effectiveness of the PSAs in relationshipto the education level of viewers. Moreover, only a small

portion of the total number of PSA viewers completed the

follow-up phone assessments. Finally, given that all mea-

sures of behavior change were self-reported and only

administered to a minority of participants, further evalua-

tion is needed to determine whether asthma knowledge and

awareness gained from student-directed PSAs really per-

sists over time, and whether this knowledge and awareness

translates into measurable behavior change leading to

improved asthma outcomes.

Conclusion

Student-directed Public Service Announcements (PSAs)

were found to significantly increase community asthma

knowledge, with some evidence that this effect may persist

over time and lead to positive behavior change. Photovoice

and media production techniques were effective in engag-

ing adolescent studentsan underserved and often disen-

franchised populationin asthma health education through

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the development and dissemination of PSAs. Participatory

techniques in the development of student-directed PSAs

hold promise for future public health initiatives, especially

those targeting adolescent youth in the context of

community.

Acknowledgments We thank the Robert Wood Johnson Foundation

for their support of this research.

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